Digital innovations for retinal care in diabetic retinopathy.

AIM: The purpose of this review is to examine the applications of novel digital technology domains for the screening and management of patients with diabetic retinopathy (DR). METHODS: A PubMed engine search was performed, using the terms "Telemedicine", "Digital health", "Telehealth", "Telescreening", "Artificial intelligence", "Deep learning", "Smartphone", "Triage", "Screening", "Home-based", "Monitoring", "Ophthalmology", "Diabetes", "Diabetic Retinopathy", "Retinal imaging". Full-text English language studies from January 1, 2010, to February 1, 2022, and reference lists were considered for the conceptual framework of this review. RESULTS: Diabetes mellitus and its eye complications, including DR, are particularly well suited to digital technologies, providing an ideal model for telehealth initiatives and real-world applications. The current development in the adoption of telemedicine, artificial intelligence and remote monitoring as an alternative to or in addition to traditional forms of care will be discussed. CONCLUSIONS: Advances in digital health have created an ecosystem ripe for telemedicine in the field of DR to thrive. Stakeholders and policymakers should adopt a participatory approach to ensure sustained implementation of these technologies after the COVID-19 pandemic. This article belongs to the Topical Collection "Diabetic Eye Disease", managed by Giuseppe Querques.

Nonmydriatic Ultra-Widefield Fundus Photography in a Hematology Clinic Shows Utility for Screening of Sickle Cell Retinopathy.

PURPOSE: To determine the feasibility and accuracy of nonmydriatic ultra-widefield (UWF) fundus photographs taken in a hematology clinic setting for screening of sickle cell retinopathy (SCR) DESIGN: Prospective cohort study. METHODS: This single-site study took place at the Johns Hopkins Sickle Cell Center for Adults and the Wilmer Eye Institute. The study population was 90 eyes of 46 consecutive adults with sickle cell disease (SCD). Bilateral nonmydriatic fundus photos taken by clinic personnel during the participants' routine hematology appointment were graded by 2 masked retina specialists at the Wilmer Eye Institute for the presence of nonproliferative SCR (NPSR) and proliferative sickle retinopathy (PSR). A third retina specialist adjudicated in cases of grader disagreement. All participants underwent the standard dilated fundus examination (DFE) within 2 years of acquisition of UWF photographs. The main outcome measure was the sensitivity and specificity of nonmydriatic UWF images for the detection of NPSR and PSR RESULTS: PSR was noted in 19 of 90 eyes that underwent DFE and in 9 of 67 gradable UWF images. Interrater agreement between the 2 graders was moderate, with κ = 0.65 (range 0.43-0.87) for PSR. For gradable UWF photos, the sensitivity and specificity of detecting SCR using the nonmydriatic photos compared with the DFE were 85.2% and 62.5% for NPSR, respectively, and 69.2% and 100% for detection of PSR, respectively. One participant required ophthalmic therapy in both eyes for active sea-fan neovascularization. CONCLUSIONS: UWF imaging shows utility in screening for SCR and may help identify patients with PSR who require a DFE and who may benefit from treatment.

Management of acute proliferative diabetic retinopathy related complications during the first COVID-19 wave.

BACKGROUND: Routine hospital eye services (HES) across the National health service (NHS), and diabetic eye screening (DES) in Scotland were paused during the COVID-19 lockdown in March 2020. Alternate pathways for managing acute ophthalmic pathology were devised in NHS Grampian covering the North-East of Scotland. Emergency eye treatment centres (EETC) manned by community optometrists were set up to treat and triage referrals to HES. METHODS: Retrospective study analysing consecutive patients referred to a tertiary eye centre (Aberdeen Royal Infirmary) with proliferative diabetic retinopathy (PDR) related complications between March and August 2020. General demographical data, diabetic history, visual acuity, ocular complication, type of management, time to follow-up, and any appointment cancellations were extracted for analysis. RESULTS: Fifty two eyes of 46 patients with PDR related complications were identified. HES appointment had been delayed or cancelled in 22 patients (48%) due to COVID-19. Mean age was 54.5 years (±15.1), 21 (46%) were female, 21 (46%) had type 1 diabetes; mean HbA1c was 78 mmol/l (±18.7). Vision ranged from 6/6 to perception of light. 36 (78%) patients had unilateral vitreous haemorrhage (VH), 6 (13%) bilateral, 2 (4%) tractional retinal detachments and 3 (6.5%) had neovascular glaucoma. Of 48 acute PDR presentations, 18 (38%) were given anti-VEGF within 72 h and two (4%) had PRP the same day. 16 (33%) were rebooked into the laser clinic, 13 (27%) referred for urgent surgical review, and 17 (35%) advised observation and review in clinic. After a median follow-up of 6 months, 12 eyes (23%) of 11 patients progressed to have vitrectomy. CONCLUSION: Despite lockdown, hospital appointment cancellations and recommended footfall reduction limiting capacity due to COVID-19, patients reaching out with PDR complications were promptly referred to HES and appropriate treatments carried out with COVID-19 precautions as recommended.

Comparison of anatomical and functional outcomes of vitrectomy with internal limiting membrane peeling in recalcitrant diabetic macular edema with and without traction in Indian patients.

PURPOSE: To study and compare the outcomes of pars plana vitrectomy (PPV) with the internal limiting membrane (ILM) peeling in the eyes with recalcitrant diabetic macular edema (DME) with and without vitreomacular traction. METHODS: A comparative prospective interventional study was undertaken in which group 1 included 45 eyes of 45 patients with DME with vitreomacular tractional component and group 2 included 45 eyes of 45 patients with recalcitrant DME without a tractional component. Both groups underwent standard PPV with ILM peeling. All the patients were followed up for a minimum of 6 months. The parameters evaluated were changes in the best-corrected visual acuity (BCVA), central macular thickness (CMT), multifocal electroretinogram (mfERG) parameters, and occurrence of any intraoperative/postoperative surgical complication. RESULTS: The mean CMT improved significantly from 540.6 and 490.2 µm at the baseline to 292.5 and 270.6 µm at 6 months in groups 1 and 2, respectively (P < 0.001). The mean BCVA logMAR improved from 0.78 ± 0.21 to 0.62 ± 0.22 in group 1 and 0.84 ± 0.19 to 0.65 ± 0.21 in group 2 at 6 months follow-up which was not statistically significant. The improvement in the mfERG was seen in group 2 as a significant increase in P1 wave amplitude in ring 2 (2-5°) (P < 0.004) and a significant decrease in P 1 wave implicit time in ring 1 (central 2°) (P < 0.001). None of the eyes suffered from the loss of BCVA or any major surgical complication in either group. CONCLUSION: PPV in recalcitrant DME provides good anatomical outcomes and the results are comparable in DME with and without a tractional component.

Situational analysis of diabetic retinopathy screening in India: How has it changed in the last three years?

Of all the eye conditions in the contemporary Indian context, diabetic retinopathy (DR) attracts the maximum attention not just of the eye care fraternity but the entire medical fraternity. Countries are at different stages of evolution in structured DR screening services. In most low and middle income countries, screening is opportunistic, while in most of the high income countries structured population-based DR screening is the established norm. To reduce inequities in access, it is important that all persons with diabetes are provided equal access to DR screening and management services. Such programs have been proven to reverse the magnitude of vision-threatening diabetic retinopathy in countries like England and Scotland. DR screening should not be considered an endpoint in itself but the starting point in a continuum of services for effective management of DR services so that the risk of vision loss can be mitigated. Till recently all DR screening programs in India were opportunistic models where persons with diabetes visiting an eye care facility were screened. Since 2016, with support from International funders, demonstration models integrating DR screening services in the public health system were initiated. These pilots showed that a systematic integrated structured DR screening program is possible in India and need to be scaled up across the country. Many DR screening and referral initiatives have been adversely impacted by the COVID-19 pandemic and advocacy with the government is critical to facilitate continuous sustainable services.

[Impact of the SARS-CoV-2 pandemic on diabetic macular edema and prognostic factors]. / Impact de la pandémie du SARS-CoV-2 sur l'œdème maculaire diabétique et facteurs pronostiques.

PURPOSE: To assess functional and anatomical consequences of the delay in intravitreal injections for diabetic macular edema (DME) patients during the corona virus pandemic lockdown in Morocco as well as to evaluate factors associated with disease progression. PATIENTS AND METHODS: This cross-sectional study included DME patients who did not complete their scheduled intravitreal bevacizumab injections during the Lockdown period (March 20, 2020 to May 20, 2020). Data recorded included age, duration of diabetes, number of previous intravitreal injections, best-corrected visual acuity, and central macular thickness before and after the lockdown. RESULTS: One hundred and fifty four eyes of 104 patients were analyzed. 57.8% were male. The mean age was 59.4±9.04 years. The mean duration of delay of intravitreal injections was 57.3±6.7 days. The mean number of intravitreal bevacizumab injections received before the lockdown was 2.29±2.1. Worsening of visual acuity was noted in 44.8% of patients and was associated with a lower number of intravitreal injections performed prior to the lockdown (P=0.001) and with glycemic imbalance (P=0.04). An increase in central macular thickness was noted in 26.6% of patients and was associated with a lower number of intravitreal injections (P=0.038). CONCLUSION: The delay in intravitreal injections during the lockdown had negative effects on visual acuity and central macular thickness in eyes with DME. Prolonged delay in intravitreal anti-VEGF injections in diabetic patients should be avoided.

The Impact of COVID-19 on Diabetic Retinopathy Monitoring and Treatment.

PURPOSE OF REVIEW: Diabetic retinopathy (DR) is one of the leading causes of vision loss worldwide. Although screening and early treatment guidelines for DR have significantly reduced the disease burden, restrictions related to the COVID-19 pandemic have changed real-world practice patterns in the management of DR. This review summarizes evolving guidelines and outcomes of the treatment of DR in the setting of the pandemic. RECENT FINDINGS: Intravitreal injections for DR have decreased significantly globally during the pandemic, ranging from approximately 30 to nearly 100% reduction, compared to corresponding timepoints in 2019. Most studies on functional outcomes show a decrease in visual acuity on delayed follow-up. Changing practice patterns in the management of DR has led to fewer intravitreal injections and overall reduction in visual acuity on follow-up. As COVID variants emerge, it will be necessary to continue evaluating practice guidelines.

Machine Learning: The Next Paradigm Shift in Medical Education.

Machine learning (ML) algorithms are powerful prediction tools with immense potential in the clinical setting. There are a number of existing clinical tools that use ML, and many more are in development. Physicians are important stakeholders in the health care system, but most are not equipped to make informed decisions regarding deployment and application of ML technologies in patient care. It is of paramount importance that ML concepts are integrated into medical curricula to position physicians to become informed consumers of the emerging tools employing ML. This paradigm shift is similar to the evidence-based medicine (EBM) movement of the 1990s. At that time, EBM was a novel concept; now, EBM is considered an essential component of medical curricula and critical to the provision of high-quality patient care. ML has the potential to have a similar, if not greater, impact on the practice of medicine. As this technology continues its inexorable march forward, educators must continue to evaluate medical curricula to ensure that physicians are trained to be informed stakeholders in the health care of tomorrow.

Diagnostic performance of deep-learning-based screening methods for diabetic retinopathy in primary care-A meta-analysis.

BACKGROUND: Diabetic retinopathy (DR) affects 10-24% of patients with diabetes mellitus type 1 or 2 in the primary care (PC) sector. As early detection is crucial for treatment, deep learning screening methods in PC setting could potentially aid in an accurate and timely diagnosis. PURPOSE: The purpose of this meta-analysis was to determine the current state of knowledge regarding deep learning (DL) screening methods for DR in PC. DATA SOURCES: A systematic literature search was conducted using Medline, Web of Science, and Scopus to identify suitable studies. STUDY SELECTION: Suitable studies were selected by two researchers independently. Studies assessing DL methods and the suitability of these screening systems (diagnostic parameters such as sensitivity and specificity, information on datasets and setting) in PC were selected. Excluded were studies focusing on lesions, applying conventional diagnostic imaging tools, conducted in secondary or tertiary care, and all publication types other than original research studies on human subjects. DATA EXTRACTION: The following data was extracted from included studies: authors, title, year of publication, objectives, participants, setting, type of intervention/method, reference standard, grading scale, outcome measures, dataset, risk of bias, and performance measures. DATA SYNTHESIS AND CONCLUSION: The summed sensitivity of all included studies was 87% and specificity was 90%. Given a prevalence of DR of 10% in patients with DM Type 2 in PC, the negative predictive value is 98% while the positive predictive value is 49%. LIMITATIONS: Selected studies showed a high variation in sample size and quality and quantity of available data.

A Smart Mobile Application to Monitor Visual Function in Diabetic Retinopathy and Age-Related Macular Degeneration: The CLEAR Study.

PURPOSE: The purpose of this study was to determine if a mobile application, the Checkup Vision Assessment System, could reliably monitor visual acuity (VA) and metamorphopsia remotely versus standard VA reference tests in the clinic. With the current COVID-19 pandemic, an even greater need for remote monitoring exists. Mobile tools enhance the ability to monitor patients virtually by enabling remote monitoring of VA and Amsler grid findings. DESIGN: Prospective, multicenter reliability analysis. METHODS: Participants: Patients (N = 108) with near corrected VA better than 20/200 and a diagnosis of age-related macular degeneration, diabetic retinopathy, or healthy patients without retinal disease (best-corrected visual acuity [BCVA] of 20/32 or better). INTERVENTION: participants were tested using the Checkup, reference VA, and Amsler tests, with the order of testing (Checkup or reference) randomized. Patients monitored their vision using Checkup at least twice a week at home between office visits. Main outcome measurements were near corrected VA and Amsler grid test results. RESULTS: Agreement was strong between Checkup and reference tests for VA (r = 0.86) and Amsler grid (sensitivity: 93%; specificity: 92%). Home versus clinic testing showed excellent agreement (r = 0.96). Patients reported successful home use. There were no serious adverse events or discontinuations. Patients rated the usability of Checkup to be excellent. CONCLUSIONS: There was good agreement between Checkup and in-clinic test results for VA and Amsler grid. The low variance of Checkup testing, agreement between in-clinic and home results, and excellent usability support Checkup as a reliable method for monitoring retinal pathology in clinic and home settings.

Patient Perceptions of SARS-CoV-2 Exposure Risk and Association With Continuity of Ophthalmic Care.

Importance: Patient perceptions regarding the risks of obtaining in-person ophthalmic care during the coronavirus disease 2019 (COVID-19) pandemic may affect adherence to recommended treatment plans and influence visual outcomes. A deeper understanding of patient perspectives will inform strategies to optimize adherence with vision-preserving therapies. Objective: To evaluate perceptions of COVID-19 exposure risk and their association with appointment attendance among patients at high risk of both reversible and irreversible vision loss from lapses in care. Design, Setting, and Participants: This survey study included a nonvalidated telephone survey designed in April and May of 2020 and a retrospective medical record review conducted in parallel with survey administration from May 22 to August 18, 2020. Participants were recruited from 2 tertiary eye care centers (Emory Eye Center in Atlanta, Georgia, and W.K. Kellogg Eye Center in Ann Arbor, Michigan). The study included a random sample of patients with diagnoses of exudative age-related macular degeneration (AMD) or diabetic retinopathy (DR) who received an intravitreal injection between January 6 and March 13, 2020, and were scheduled for a second injection between March 13 and May 6, 2020. Main Outcomes and Measures: Association between perceptions regarding COVID-19 risks and loss to follow-up. Results: Of 1004 eligible patients, 423 (42%) were successfully contacted, and 348 (82%) agreed to participate (participants' mean [SD] age, 75 [12] years; 195 women [56%]; 287 White [82%] patients). Respondents had a mean (SD) of 2.7 (1.1) comorbidities associated with severe COVID-19, and 77 (22%) knew someone with COVID-19. Of all respondents, 163 (47%) were very concerned or moderately concerned about vision loss from missed treatments during the pandemic. Although 208 (60%) believed the COVID-19 virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), exposure at the eye clinic was extremely unlikely or unlikely, 49 (14%) believed it was extremely likely or likely. Seventy-eight participants (22%) were lost to follow-up. Concern regarding COVID-19 exposure during clinic visits (odds ratio [OR], 3.9; 95% CI, 1.8-8.4) and diagnosis of DR (vs AMD) (OR, 8.130; 95% CI, 3.367-20.408) were associated with an increase in likelihood of loss to follow-up. Conclusions and Relevance: Among patients at high risk for vision loss from lapses in care, many expressed concerns regarding the effect of the pandemic on their ability to receive timely care. Survey results suggest that fear of SARS-CoV-2 exposure was associated with a roughly 4-fold increase in the odds of patient loss to follow-up. These results support the potential importance of clearly conveying infection-control measures.

Diabetic retinopathy screening in urban primary care setting with a handheld smartphone-based retinal camera.

AIMS: To evaluate diabetic retinopathy (DR) screening with a portable handheld smartphone-based retinal camera and telemedicine in an urban primary healthcare setting and to evaluate the learning curve for image acquisition, performed by healthcare personnel without previous experience in retinal imaging. METHODS: This was a prospective study that enrolled patients with type 2 diabetes mellitus (T2DM) followed at a primary healthcare unit in São Paulo, Brazil. After a brief training in image acquisition, there was further continuous feedback given by a retina specialist during the remote image reading process. Each patient underwent two fundus and one anterior ocular segment images per eye, after mydriasis. Patients were classified according to the need of referral. RESULTS: A total of 627 adult individuals with T2DM underwent retinal evaluation. The population was composed by 63.2% female individuals, age median of 66 years, diabetes duration 10.7 ± 8.2 years and HbA1c 7.7 ± 1.9% (61 + 20.8 mmol/mol). The most prevalent associated comorbidities were arterial hypertension (80.3%) and dyslipidemia (50.2%). Referral decision was possible in 81.2% patients. Most patients had absent or non-referable DR; the main ocular media opacity detected was cataract. After the 7th day of image acquisition, the daily rate of patients whose images allowed clinical decision was maintained above 80%. A higher HbA1c was associated with referable DR. CONCLUSIONS: A low-cost DR screening strategy with a handheld device and telemedicine is feasible and has the potential to increase coverage of DR screening in underserved areas; the possibility of mobile units is relevant for DR screening in the context of COVID-19 pandemic. Daily rate of patients whose examinations allowed clinical decision. X-axis: day of examination; Y-axis: rate (%) of patients whose examinations allowed a clinical decision.

Digital Ophthalmology in the UK - Diabetic Retinopathy Screening and Virtual Glaucoma Clinics in the National Health Service. / Digitale Ophthalmologie in Großbritannien ­ Diabetische-Retinopathie-Screening und virtuelle Glaukomsprechstunde im National Health Service.

The customary doctor and patient interactions are currently undergoing significant changes through technological advances in imaging and data processing and the need for reducing person-to person contacts during the COVID-19 crisis. There is a trend away from face-to-face examinations to virtual assessments and decision making. Ophthalmology is particularly amenable to such changes, as a high proportion of clinical decisions are based on routine tests and imaging results, which can be assessed remotely. The uptake of digital ophthalmology varies significantly between countries. Due to financial constraints within the National Health Service, specialized ophthalmology units in the UK have been early adopters of digital technology. For more than a decade, patients have been managed remotely in the diabetic retinopathy screening service and virtual glaucoma clinics. We describe the day-to-day running of such services and the doctor and patient experiences with digital ophthalmology in daily practice.

The Importance of Telemedicine during COVID-19 Pandemic: A Focus on Diabetic Retinopathy.

Recently, telemedicine has become remarkably important, due to increased deployment and development of digital technologies. National and international guidelines should consider its inclusion in their updates. During the COVID-19 pandemic, mandatory social distancing and the lack of effective treatments has made telemedicine the safest interactive system between patients, both infected and uninfected, and clinicians. A few potential evidence-based scenarios for the application of telemedicine have been hypothesized. In particular, its use in diabetes and complication monitoring has been remarkably increasing, due to the high risk of poor prognosis. New evidence and technological improvements in telemedicine application in diabetic retinopathy (DR) have demonstrated efficacy and usefulness in screening. Moreover, despite an initial increase for devices and training costs, teleophthalmology demonstrated a good cost-to-efficacy ratio; however, no national screening program has yet focused on DR prevention and diagnosis. Lack of data during the COVID-19 pandemic strongly limits the possibility of tracing the real management of the disease, which is only conceivable from past evidence in normal conditions. The pandemic further stressed the importance of remote monitoring. However, the deployment of device and digital application used to increase screening of individuals and monitor progression of retinal disease needs to be easily accessible to general practitioners.

Artificial intelligence for diabetic retinopathy screening, prediction and management.

PURPOSE OF REVIEW: Diabetic retinopathy is the most common specific complication of diabetes mellitus. Traditional care for patients with diabetes and diabetic retinopathy is fragmented, uncoordinated and delivered in a piecemeal nature, often in the most expensive and high-resource tertiary settings. Transformative new models incorporating digital technology are needed to address these gaps in clinical care. RECENT FINDINGS: Artificial intelligence and telehealth may improve access, financial sustainability and coverage of diabetic retinopathy screening programs. They enable risk stratifying patients based on individual risk of vision-threatening diabetic retinopathy including diabetic macular edema (DME), and predicting which patients with DME best respond to antivascular endothelial growth factor therapy. SUMMARY: Progress in artificial intelligence and tele-ophthalmology for diabetic retinopathy screening, including artificial intelligence applications in 'real-world settings' and cost-effectiveness studies are summarized. Furthermore, the initial research on the use of artificial intelligence models for diabetic retinopathy risk stratification and management of DME are outlined along with potential future directions. Finally, the need for artificial intelligence adoption within ophthalmology in response to coronavirus disease 2019 is discussed. Digital health solutions such as artificial intelligence and telehealth can facilitate the integration of community, primary and specialist eye care services, optimize the flow of patients within healthcare networks, and improve the efficiency of diabetic retinopathy management.